Content of ecstasy in the Netherlands: 1993-2008

Monitoring trends in recreational drug use from the analysis of the contents of amnesty bins in gay dance clubs

BACKGROUND

In 2011/12, 8.9% of the UK population reported use of recreational drugs. Problems related to drug use is a major financial burden to society and a common reason for attendance to hospital.

AIM

The aim of this study was to establish current trends in recreational drug use amongst individuals attending gay-friendly nightclubs in South London.

METHOD

Contents of drug amnesty bins located at two night clubs were documented and categorized into powders, herbal products, liquids, tablets and capsules. These were then sent to a Home Office licensed laboratory for identification through a pre-existing database of almost 25 000 substances. If required, further qualitative analysis was performed.

RESULTS

A total of 544 samples were obtained. Of them, 240 (44.1%) were liquids, 220 (40.4%) powders, 42 (7.7%) herbal and 41 (7.5%) tablets or capsules. Gamma-butyrolactone (GBL) was the most common liquid drug (n = 160, 66.7%) followed by poppers (n = 72, 30.0%). Powders provided the widest range of drugs with mephedrone being the most common (n = 105, 47.7%) followed by ketamine (n = 28, 12.7%), 3,4-methylenedioxy-N-methylamphetamine (MDMA) (n = 26, 11.8%), and cocaine (n = 21, 9.5%). Tablets and capsules included medicinal drugs, recreational drugs and plaster of Paris tablets that mimicked the appearance of 'ecstasy' tablets.

CONCLUSION

This study has provided a snapshot of the pattern of drug use in the gay community which compliments findings of the self-reported surveys and other studies from the same population. The information obtained will be helpful in guiding in designing harm reduction interventions in this community and for monitoring the impact of changes in legislation.

3,4-methylenedioxymethamphetamine (MDMA): current perspectives

Ecstasy is a widely used recreational drug that usually consists primarily of 3,4-methylenedioxymethamphetamine (MDMA). Most ecstasy users consume other substances as well, which complicates the interpretation of research in this field. The positively rated effects of MDMA consumption include euphoria, arousal, enhanced mood, increased sociability, and heightened perceptions; some common adverse reactions are nausea, headache, tachycardia, bruxism, and trismus. Lowering of mood is an aftereffect that is sometimes reported from 2 to 5 days after a session of ecstasy use. The acute effects of MDMA in ecstasy users have been attributed primarily to increased release and inhibited reuptake of serotonin (5-HT) and norepinephrine, along with possible release of the neuropeptide oxytocin. Repeated or high-dose MDMA/ecstasy use has been associated with tolerance, depressive symptomatology, and persisting cognitive deficits, particularly in memory tests. Animal studies have demonstrated that high doses of MDMA can lead to long-term decreases in forebrain 5-HT concentrations, tryptophan hydroxylase activity, serotonin transporter (SERT) expression, and visualization of axons immunoreactive for 5-HT or SERT. These neurotoxic effects may reflect either a drug-induced degeneration of serotonergic fibers or a long-lasting downregulation in 5-HT and SERT biosynthesis. Possible neurotoxicity in heavy ecstasy users has been revealed by neuroimaging studies showing reduced SERT binding and increased 5-HT_2A receptor binding in several cortical and/or subcortical areas. MDMA overdose or use with certain other drugs can also cause severe morbidity and even death. Repeated use of MDMA may lead to dose escalation and the development of dependence, although such dependence is usually not as profound as is seen with many other drugs of abuse. MDMA/ecstasy-dependent patients are treated with standard addiction programs, since there are no specific programs for this substance and no proven medications. Finally, even though MDMA is listed as a Schedule I compound by the Drug Enforcement Agency, MDMA-assisted psychotherapy for patients with chronic, treatment-resistant posttraumatic stress disorder is currently under investigation. Initial results show efficacy for this treatment approach, although considerably more research must be performed to confirm such efficacy and to ensure that the benefits of MDMA-assisted therapy outweigh the risks to the patients.

Human psychobiology of MDMA or 'Ecstasy': an overview of 25 years of empirical research

AIMS

This paper aimed to review how scientific knowledge about the human psychobiology of MDMA has developed over time.

METHODS

In this paper, the empirical findings from earlier and later studies will be reviewed.

RESULTS

When MDMA was a 'novel psychoactive substance', it was not seen as a drug of abuse, as it displayed loss of efficacy. However, recreational users display a unique pattern of increasing doses, deteriorating cost-benefit ratios, and voluntary cessation. MDMA increases body temperature and thermal stress, with cortisol levels increased by 800% in dance clubbers. It can be extremely euphoric, although negative moods are also intensified. MDMA causes apoptosis (programmed cell death) and has been investigated for cancer therapy because of its anti-lymphoma properties. Recreational users show deficits in retrospective memory, prospective memory, higher cognition, problem solving, and social intelligence. Basic cognitive skills remain intact. Neuroimaging studies show reduced serotonin transporter levels across the cerebral cortex, which are associated with neurocognitive impairments. Deficits also occur in sleep architecture, sleep apnoea, complex vision, pain, neurohormones, and psychiatric status. Ecstasy/MDMA use during pregnancy leads to psychomotor impairments in the children.

CONCLUSIONS

The damaging effects of Ecstasy/MDMA are far more widespread than was realized a few years ago, with new neuropsychobiological deficits still emerging.

Analysis of anonymous pooled urine from portable urinals in central London confirms the significant use of novel psychoactive substances

AIM

Analysis of urine samples collected across a city centre, for the detection of novel psychoactive substances (NPS).

DESIGN

Cross-sectional study of anonymized urine samples used for the analysis of classical recreational drugs, NPS and metabolites.

METHODS

Pooled urine samples collected from portable stand-alone four-person urinals across a city centre were analysed using full-scan accurate-mass high-resolution liquid chromatography coupled to tandem mass spectrometry. Data were processed against compound databases containing >1700 drug compounds and metabolites.

RESULTS

Seven established recreational drugs (3,4-methylenedioxyamphetamine, cocaine, cannabis, ketamine, 3,4-methylenedioxy-N-methylamphetamine, methamphetamine and amphetamine) and six potential NPS [hordenine (all 12 urinals), cathine (11), methylhexaneamine (9), 4-methylmethcathinone (6), methiopropamine and metabolites (2) and methoxetamine and metabolites (1)] were detected. Methylhexaneamine, methiopropamine and hordenine are currently uncontrolled in the UK, whereas methoxetamine is currently subject to a Temporary Class Drug Order. Metabolites of the anabolic steroid nandrolone were found in two urinals and trenbolone metabolites and clenbuterol in one urinal.

CONCLUSION

Analysis of pooled urine samples collected anonymously from stand-alone urinals in a large inner city can detect the use of recreational drugs, NPS and anabolic steroids. Metabolite detection indicates actual drug use, metabolism and elimination rather than simply discarded drugs in the urinals. This technique by confirming the actual drug(s) used has the potential to be additive to currently used datasets/key indicators providing more robust information for healthcare authorities, legislative and law enforcement on the drugs actually being used.

Linking the pharmacological content of ecstasy tablets to the subjective experiences of drug users

RATIONALE

Most studies on the subjective effects of ecstasy are based on the assumption that the substance that was taken is 3,4-methylenedioxymethamphetamine (MDMA). However, many tablets sold as ecstasy contain other substances and MDMA in varying doses. So far, few attempts have been made to take this into account while assessing subjective effects.

OBJECTIVES

This study aims to link the pharmacological content of tablets sold as ecstasy to the subjective experiences reported by ecstasy users.

METHODS

Self-reported effects on ecstasy tablets were available from 5,786 drug users who handed in their tablets for chemical analysis at the Drug Information and Monitoring System (DIMS) in the Netherlands. Logistic regression was employed to link the pharmacological content of ecstasy tablets to the self-reported subjective effects and compare effects with MDMA to other substances present.

RESULTS

MDMA showed a strong association with desirable subjective effects, unparalleled by any other psychoactive substance. However, the association of MDMA was dose-dependent, with higher doses (>120 mg/tablet) likely to evoke more adverse effects. The novel psychostimulants mephedrone and p-fluoroamphetamine were considered relatively desirable, whereas meta-chlorophenylpiperazine (mCPP) and p-methoxymethamphetamine (PMMA) were strongly associated with adverse subjective effects. Also, 3,4-methylene-dioxyamphetamine (MDA) and benzylpiperazine (BZP) were not appreciated as replacement for MDMA.

CONCLUSION

Linking the pharmacological content of ecstasy sold on the street to subjective experiences contributes to a better understanding of the wide range of subjective effects ascribed to ecstasy and provides a strong rationale for the prolonged endurance of MDMA as the key ingredient of the ecstasy market.

Instability of the ecstasy market and a new kid on the block: mephedrone

Recently, several reports have indicated instability of the ecstasy market in the Netherlands and other EU countries. In the current study, we demonstrate this instability in the Netherlands, showing a decrease of ecstasy tablets containing 3,4-methylenedioxymetamphetamine (MDMA) by more than 50% in 2009. In addition, we describe a partial replacement of MDMA in tablets sold as ecstasy by a previously unseen substance, mephedrone (or 4-methylmethcathinone). Mephedrone was quantified and ecstasy tablets contained between 96 and 155 mg of this new compound. So far, no studies about mephedrone's effects have been published. For this study, we gathered information on the acute subjective effects of mephedrone from 70 regular ecstasy users. Overall, the majority of users considered the effects enjoyable. Mephedrone seemed to evoke effects similar to other amphetamine type psychostimulants, including MDMA. In contrast to MDMA, however, mephedrone induced strong feelings of craving in most users. If the unstable ecstasy market situation persists, the potential of mephedrone to substitute for MDMA might be substantial. Mephedrone, sold as ecstasy, is therefore likely to be a valid cause for health concern.

Association of study characteristics with estimates of effect size in studies of ecstasy use

Studies of the chronic effects of MDMA, or 'ecstasy', in humans have been largely inconsistent. We explored whether study-level characteristics are associated with the effect size estimate reported. We based our analyses on the recent systematic review by Rogers and colleagues, focusing on those meta-analyses within this report where there was a relatively large number of studies contributing to each individual meta-analysis. Linear regression was used to investigate the association between study level variables and effect size estimate, weighted by the inverse of the SE of the effect size estimate, with cluster correction for studies which contributed multiple estimates. This indicated an association between effect size estimate and both user group, with smaller estimates among studies recruiting former users compared with those recruiting current users, and control group, with smaller estimates among studies recruiting polydrug user controls compared with those recruiting drug-naïve controls. In addition, increasing year of publication was associated with reduced effect size estimate, and there was a trend level association with prevalence of ecstasy use, reflecting smaller estimates among studies conducted in countries with higher prevalence of ecstasy use. Our data suggest a number of study-level characteristics which appear to influence individual study effect size estimates. These should be considered when designing future studies, and also when interpreting the ecstasy literature as a whole.

Event related potential (ERP) evidence for selective impairment of verbal recollection in abstinent recreational methylenedioxymethamphetamine ("Ecstasy")/polydrug users

OBJECTIVES

Ecstasy is a recreational drug whose active ingredient, 3,4-methylenedioxymethamphetamine (MDMA), acts predominantly on the serotonergic system. Although MDMA is known to be neurotoxic in animals, the long-term effects of recreational Ecstasy use in humans remain controversial but one commonly reported consequence is mild cognitive impairment particularly affecting verbal episodic memory. Although event-related potentials (ERPs) have made significant contributions to our understanding of human memory processes, until now they have not been applied to study the long-term effects of Ecstasy. The aim of this study was to examine the effects of past Ecstasy use on recognition memory for both verbal and non-verbal stimuli using ERPs.

METHODS

We compared the ERPs of 15 Ecstasy/polydrug users with those of 14 cannabis users and 13 non-illicit drug users as controls.

RESULTS

Despite equivalent memory performance, Ecstasy/polydrug users showed an attenuated late positivity over left parietal scalp sites, a component associated with the specific memory process of recollection.

CONCLUSIONS

[corrected] This effect was only found in the word recognition task which is consistent with evidence that left hemisphere cognitive functions are disproportionately affected by Ecstasy, probably because the serotonergic system is laterally asymmetrical. Experimentally, decreasing central serotonergic activity through acute tryptophan depletion also selectively impairs recollection, and this too suggests the importance of the serotonergic system. Overall, our results suggest that Ecstasy users, who also use a wide range of other drugs, show a durable abnormality in a specific ERP component thought to be associated with recollection.

Pharmacodynamic interactions between MDMA and concomitants in MDMA tablets on extracellular dopamine and serotonin in the rat brain

3,4-methylenedioxymethamphetamine (MDMA) is a psychoactive stimulant abused by young people as the recreational drug ecstasy. Other compounds, either deliberately added or present as byproducts, are often found in MDMA tablets and can unexpectedly interact with each other. The aim of this study was to evaluate the pharmacodynamic effects of interactions caused by concomitants in MDMA tablets on extracellular dopamine and serotonin (5-HT) by microdialysis in the striatum of ethylcarbamate-anesthetized rats. Baseline levels of dopamine and 5-HT in the striatum were 16.5±7.7 and 3.5±1.7 nM (mean±standard deviation), respectively. After a single administration of MDMA (10 mg/kg, i.p.), a dramatic increase in extracellular dopamine (Cmax: 36.1-fold vs. baseline) and 5-HT levels (Cmax: 9.3-fold vs. baseline) was observed. When rats were co-administered with methamphetamine (1, 5 or 10 mg/kg) with MDMA, the dopamine levels induced by MDMA increased in a methamphetamine-dose-dependent manner (Cmax: 2.5-, 3.5-, and 3.8-fold vs. MDMA). A similar trend was observed in 5-HT levels (Cmax: 1.1-, 1.3-, and 1.8-fold vs. MDMA). In contrast, ketamine and caffeine showed synergistic effects on the monoamine levels induced by MDMA, whereas the individual administration of either of these compounds did not affect monoamine levels. Ketamine (1, 5 mg/kg) decreased the dopamine levels induced by MDMA (Cmax: 0.9- and 0.7-fold vs. MDMA) and increased the 5-HT levels induced by MDMA (Cmax: 1.4- and 1.6-fold vs. MDMA), and co-administration of caffeine (20 mg/kg) with MDMA increased dopamine levels (Cmax: 1.7-fold vs. MDMA). These results suggest that exposure to multiple drugs in addition to MDMA can have neurotoxic effects.